Table 5.
Contributory and/or associated factors to patient safety issue occurrence across included studies
| Study (first author, year) |
Institutional Context Factors [ICF] | Organisational & Management Factors [OMF] | Work Environmental Factors [WEF] | Task and Technology Factors [TTF] | Individual (staff) Factors [ISF] | Team Factors [TF] | Patient factors [P] | Factor examples | Implied direction of factor(s) effect for patient safety |
|---|---|---|---|---|---|---|---|---|---|
| Storeng (2012) [37] | 1 | [ICF] Payments for care | Negative | ||||||
| Maly (2011) [57] | 1 | 3 | [P]: 1) Race 2) patient self-efficacy and3) cultural beliefs affecting care. [ISF]: clinical breast examination had longer delay than by mammogram. | Negative | |||||
| Abizanda (2014) [34] | 1 | 3 | [P]: 1) Frailty, 2) Institutionalisation and 3) disability | Negative | |||||
| Beck (2017) [38] | 1 | [ICF] Payments for care | Negative | ||||||
| Cromwell (2005) [79] | 1 | [P] Race | Negative | ||||||
| da Costa (2016a) [62] | None measured | Not applicable | |||||||
| da Costa (2016b) [75] | None measured | Not applicable | |||||||
| DeVylder (2015) [77] | 2 | [P]:1) Psychosis and 2)suicidality | Negative | ||||||
| deBruijne (2013) [71] | 1 | 1 | [P]:Ethnicity and Payments for care [ICF] | Negative | |||||
| Dent (2014) [80] | 1 | [P]:Frailty | Negative | ||||||
| Desai (2013) [76] | 2 | [P]:Age, and mental capacity (cognitive ability) | Negative | ||||||
| Ekerstad (2017) [49] | 1 | 2 | [ICF:]Under-use evidence-based drug treatment and [P]: 1) heart failure and 2) anaemia were predictors for readmission | Negative | |||||
| Friedman (2008) [51] | 6 | [P]: 1) Worsening function, 2) delirium, 3) depression, 4) falls, 5) pressure sores, and 6) admission from a nursing home. | Negative | ||||||
| Garrett (2008) [63] | 2 | 1 | [WEF] staff workload/pressures and staff neglect, [P] communication/language | Negative | |||||
| Gaskin (2011) [56] | 1 | [P] No associations for ethnicity | Neutral | ||||||
| Groene (2012) [42] | 1 | 1 | [OMF]: No commonly accepted standard operating procedures for the exchange of information between secondary care and primary care. Communication and role of patient within discharge variable and unclear [ICF] | Negative | |||||
| Hastings (2008) [50] | 1 | [P] Frailty | Negative | ||||||
| Haw 2003 [61] | 2 | [ISF] Decision-making errors and Errors in prescription writing | Negative | ||||||
| Heyland, 2016 [35] | 2 | [P] Frailty and social support | Negative | ||||||
| Hole 2015 [43] | 1 | 2 | [P] perceived discrimination and Interpersonal experiences of marginalization (e.g. not being listened to/believed judged in a negative light)) [P]. [ICF] Structural factors. | Negative | |||||
| Hubbard 2017 [65] | 1 | [P] Frailty | Negative | ||||||
| Katzenellenbogen (2013) [60] | 3 | [P]: emergency admission, alcohol admission with or without mental health-related admission history and Aboriginality | Negative | ||||||
| Khaykin (2010) [64] | 1 | 1 | [P] Schizophrenia and [TF] effective communication among healthcare providers and between health care providers and this vulnerable patient population. | Negative | |||||
| Lahousse (2014) [48] | 1 | Access to care - hospital care unaffordable [ICF], poor women-professional communication [ISF], obstetric professionals busy and lack of time [WEF]; mothers felt clinical team unqualified to diagnose illness [P]; low education levels /illiteracy [P] | Negative | ||||||
| Latham (2011) [47] | None measured | Not applicable | |||||||
| Lin (2011) [54] | 1 | [P] Intellectual Disability patients - Complications correlated with ID severity, especially in septicaemia. | Negative | ||||||
| Marcus (2018) [55] | None stated - measures of events, preventability and harm but not cause. | Not applicable | |||||||
| Reime (2012) [73] | 1 | [P] ethnicity (Women from the Middle East, Asia and Africa/Latin America vs. women from Germany). These differences were not explained by the sociodemographic, behavioural or health-related factors. | Negative | ||||||
| Sarkar (2010) [69] | 1 | 2 | 2 | [ICF] Systems issues, patient physician communication problems [P] + [ISF], and clinician [ISF] and patient actions-[P] | Negative | ||||
| Shen (2016) [53] | 1 | [P] Poverty | Negative | ||||||
| Stenhouse (2013) [44] | 1 | [OMF] No perceived polices for safeguarding | Negative | ||||||
| van Rosse (2016a) [8] | 2 | 1 | [ISF]1) daily clinician practices e.g. ‘drop-out’ of protocolised name and/or date-of-birth checks not done during critical care moments due to language barriers and 2) lack of use of professional interpreters despite 3/4 hospitals having an explicit policy to encourage use (policies not enacted). Language barriers [P] | Negative | |||||
| van Rosse (2016b) [36] | 2 | 1 | [P] language and communication issues due to role of relatives | Unclear | |||||
| Van Rosse (2014) [81] | 1 | There was no significant difference in the incidence of AEs in Dutch patients and in ethnic minority patients [P]. | Neutral | ||||||
| Zaal (2013) [52] | 1 | 1 | 1 | [ISF] physicians may prescribe drugs more carefully to individuals with a more severe ID, resulting in fewer errors. [P] Individuals with a more severe ID are being treated in centralized settings [P]. [OMF] Centralised settings employ specialized physicians for people with intellectual disabilities more often. | Positive | ||||
| Bennett (2014) [70] | 1 | [P] Frailty | Negative | ||||||
| Berry (2017) [41] | 3 | [P] 1) Cognitive decline (Alzheimer’s), 2) social support (as carers taking over medication management) and 3) elder resistance to medication-taking. | Unclear | ||||||
| Bickley (2006) [67] | 2 | 1 | 1 | 1 | lack of supervision [WEF], poor patient compliance with medication [P], knowledge of staff [ISF], staffing levels [WEF] and poor communication [TF]. | Negative | |||
| Boockavar (2004) [83] | 1 | Transitions/discharge related medication issues (between hospitals and nursing homes) [ICF] | Negative | ||||||
| Briesacher (2005) [82] | 1 | 1 | [ICF] National policy changes designed to affect the use of potentially inappropriate medications and implementation practices of care homes [OMF] led to variation in prescribing of potentially inappropriate medications. | Negative | |||||
| Bronskill (2012) [74] | 1 | [OMF] variation in polypharmacy rates across care homes | Negative | ||||||
| Cantarero (2014) [40] | 4 | [P] Multiple perceptions of medicines and medicine-related problems: 1) not taking meds from Danish doctors, inherited incorrect information from their parents, 2) perceived differences in treatment from doctors due to foreign status, 3) impossible to understand the instructions and recommendations of their doctor in Danish and 4) specific needs concerning appropriate medicine use and information. | Negative | ||||||
| Castle and Engberg (2007) [85] | 1 | [OMF] Size of the nursing home and [ICF] Medicaid reimbursement rates. | Positive | ||||||
| Ferguson (2015) [39] | 1 | 2 | [P] 1) unable to communicate due to deafness/Hard of hearing (HOH) and 2) experiencing an adverse event due to deafness/HOH and [ISF] perceived lack of sensitivity by pharmacists | Negative | |||||
| Hoffman (2003) [78] | None stated | Not applicable | |||||||
| Poudel (2016) [72] | [P] Frailty | Negative | |||||||
| Adisasmita (2015) [84] | 1 | 1 | 2 | [P] 1) Poverty and 2) delivery outside the hospital are significant risk factors associated with near miss. Hospital/staff practices [ISF] and [OMF] response time. | Negative | ||||
| Kandil (2012) [66] | 4 | [ISF] Administration errors were either due to: wrong 1) rate 2) dose, 3) route or 4) time of administration of the drug. | Negative | ||||||
| Roost (2009) [87] | 3 | [P] 1) Strategies shaped by family traditions and composed experiences 2) The perception of not belonging (lack of knowledge, fears of hospital); 3) Mistreatment and distrust. | Negative | ||||||
| Drumond 2013 [58] | 2 | [P]: Ethnicity and socioeconomic status. | Negative | ||||||
| Fernandes 2017 [59] | 1 | [ICF] Inadequate healthcare access | Negative | ||||||
| Mohammadi 2017a [45] | 1 | 1 | 1 | 4 | [ICF] Access to care - hospital care unaffordable, poor women-professional communication [ISF], obstetric professionals busy and lack of time [WEF]; mothers felt clinical team unqualified to diagnose illness [P]; low education levels /illiteracy [P] cited as an issue. Lack of understanding caused women to not question health professionals [P]. discrimination - voice not being heard particularly by midwives and feeling as though treated differently [P]. | Negative | |||
| Mohammadi (2017b) [68] | 4 | Illiteracy [P] and having only primary education [P], low income status [P] and being Afghan [P] | Negative | ||||||
| Zhi-Han (2017) [46] | 1 | [P] vision problems (inability to read the prescription labels) | Negative | ||||||
| Corsonello (2009) [32] | none stated | Not applicable | |||||||
| Khanassov (2016) [29] | None stated | Not applicable | |||||||
| Pepper 2007 [27] | 5 | [P]: 1) female sex, 2) caucasian,3) great number of medication prescriptions, 4) age less than 85 and 5) not having cognitive impairment. | Negative | ||||||
| Castro 2015 [31] | 1 | 1 | [ISF] Poor communication derived from healthcare professionals not communicating in indigenous languages and resulting in poor quality access to healthcare [ICF]. | Negative | |||||
| Hemsley 2014 [33] | 1 | 1 | 2 | 2 | (a) services, systems, and policies needed that support improved communication [ICF], (b) enough time to communication [WEF], (c) ensure adequate access to communication tools (nurse call systems and communication aids [TTF], (d) access personally held written health information [TTF], (e) collaborate effectively with carers, spouses, and parents,[ISF] and (f) increase the communicative competence of hospital staff [ISF]. | Negative | |||
| Alhomoud 2013 [30] | 1 | 3 | [P]:1) In ethnic minority groups differing cultural perceptions or beliefs about health, illness, prescribed treatment and medical care impact on the use of medicines. 2) Ethnic minority groups have different experiences, needs, values and expectations of illness, prescribed treatment and medical care 3) Language and communication barriers have been identified as a possible contributory factor to Medicine Related Problems.[ISF]: inability to communicate in what is not the ethnic minorities’ mother tongue may lead to discrimination | Negative | |||||
| Almeida 2013 [28] | 1 | 2 | 2 | [ICF]: reduced access to health facilities. [ISF]:1) poor communication between providers and patients and 2) less follow-up. [P] 1) higher health risk profile in immigrants and 2) high likelihood of comorbidities. | Negative | ||||
| Hoffmann 2019 [36] | 3 | [P]: 1) Age, 2) gender and 3) condition (dementia vs. non-dementia) | Unclear | ||||||
| Stajduhar 2019 [91] | 2 | 1 | 1 | 1 | [ICF]: 1) social disadvantages and oppressions and 2) The cracks of a ‘silo-ed’ care system. [P]: The normalization of dying (form of fatalism). [ISF]:The problem of identification [OMF] Professional risk and safety management | Negative | |||
| Komiya 2018 [92] | 7 | [P]: 1) lower care need level, 2) higher Barthel Index (BI), 3) higher Mini-Nutritional Self-Assessment Short Form (MNA-SF), 4) lower Charlson Comorbidity Index (CCI), 5) the presence of Potentially Inappropriate Medicines (PIM), 6) the presence of pollakisuria, 7) presence of insomnia | Unclear | ||||||
| Katikireddi 2018 [93] | 1 | [P]: Ethnicity | Mixed effects | ||||||
| Gamlin 2018 [94] | 1 | 2 | 1 | [WEF]: 1) the structure of service provision, in which providers have several contiguous days off, [ISF] 1) poor patient-provider dynamic and discriminatory practices and 2) sometimes non-consensual imposition of biomedical practices. [P] men have important roles to play supporting their partners during labour and birth. | Negative | ||||
| Funk 2018 [95] | 3 | [P]: 1) Health care communication difficulties due to patient non-disclosure of condition, 2) passivity and vulnerability, and 3) frustration with family | Negative |